Minimally Invasive Surgery: Continued Growth Opens New Doors

By Michelle Beaver

UNLIKE BELL BOTTOMS, PET ROCKS, AND BEEHIVE HAIR-DOS, minimally invasive surgery (MIS) is here to stay, as what started out as an exception is morphing into the rule. Since MIS is completed without major incisions, it is often cheaper and allows the patient to heal faster, which means shorter stays and less therapy. Additional benefits include minimal scarring, a decreased need for post surgical pain medication, and a smaller likelihood that complications will occur.¹ MIS is not the same as a minor surgery, however, and should not be underestimated, for while the incision, camera, and auxiliary devices such as irrigation and drainage tools used during “minimally” invasive procedures are small, the dangers are not. Even so, MIS is going to keep getting more popular, and will continue to be a significant part of the bottom line at ASCs across the country.

Wave of the Future

Laparoscopic surgery is generally “superior” to alternatives, says George C. Christoudias, MD. He is trained in general surgery and surgical oncology and has been practicing at Holy Name Hospital in Teaneck, N.J, since 1979. Christoudias has performed spleenectomies, cholecystectomies, herniorrhaphies, appendectomies, lymph node biopsies, colectomies, and diagnostic laparoscopies, etc.

“When it comes to patient comfort and speed of recovery and return to normal activity, there is no comparison, by any account, between the outcomes of laparoscopic versus conventional surgery,” Christoudias says.

“Laparaoscopic surgery has come a long way in the passed years,” he adds. “I believe, however, that it is still at a very young age. I am sure we will see much more advanced technology in the future, which will carry the laparoscopic procedures to a higher level.”

The trend will indeed gather steam, says David Shapiro, MD, CHC, CPHRM, LHRM, AAAHC who is a board member of the American Association of Ambulatory Surgery Centers (AAASC).

“There’s no doubt (that MIS will continue to grow and compete with traditional surgery). Not even discussable,” Shapiro says. “I think techniques are going to continue to develop and I think that’s clearly the way they’re going. If you just look at surgical procedures over the last year or 100 years, that is clearly the direction in which they’re moving.

“When my parents and especially my grandparents went in for a cataract procedure, that was an inpatient procedure and you stayed in bed for a week in the hospital,” Shapiro says, “and now you can be literally in and out of the surgery centers within one or two hours.

Indeed, the strain on patients is decreasing. “The majority of the patients out there are having just topical anesthesia with drops that are administered immediately prior to the start of surgery so that the patient isn’t exposed to all the potential side effects of the block,” he adds. “… the general trend is the exponential use of laparoscopic surgery. (It) absolutely has reduced operating room (OR) time, and it has reduced infections and perioperative mortality. It’s all-around better for the patient. It was a generation ago that it was almost unheard of, and now it’s almost unheard of to have an open procedure.”

Different Strokes for Different Folks

Sure, laparoscopic surgery is often the way to go, but not always, according to Shapiro.

“Each patient is individual and each procedure is individual and if I’m doing ‘x’ procedure on patient ‘y,’ if we do it today, what may be the best thing for that patient may be different next week or the week prior,” he says. “All those variables have to be absolutely individualized. Every time that you move away from that, you risk the potential of overlooking an issue that’s very specific to that patient… it cuts across all levels of the practice of medicine. It’s not just surgery, it’s not just anesthesia and it’s certainly not just in the ASC environment.”

Gray areas abound and even the term “minimally invasive surgery” is open to interpretation, Shapiro says.

“Everything’s relative,” he adds, “so when you get to a term like ‘minimal’ it’s very unquantifiable.”

New Strategies in Polyp Surgeries

Laparoscopy is making waves in many arenas, particularly when it comes to removal of stubborn polyps, such as those that are flattened against the colon or that are in otherwise difficult-to-reach places. 

These polyps should be removed, since they may lead to malignant cancers. This has traditionally called for open surgery and a hospital stay of three to seven days, according to colon and rectal surgeons who helped develop the procedure at New York City’s New York-Presbyterian Hospital/Weill Cornell Medical Center.

Thanks to an experimental procedure of laparoscopic surgery combined with carbon dioxide-assisted colonoscopy, most patients can go home in less than a day, surgeons state in a paper called, “New combined laparoscopy and colonoscopy procedure may avoid need for major surgery.”2

According to the paper, the polyp procedure is “a combination of traditional colonoscopy and laparoscopic surgery, in which surgeons inflate the colon with CO2, locate the polyp via colonoscopy, then use new laparoscopic techniques to facilitate the endoscopic removal of the lesion. The procedure can be augmented and made safer with a few quick sutures placed laparoscopically where the polyp once was.”

“Unlike regular air that is used in traditional colonoscopic procedures, carbon dioxide doesn’t cause the patient to get bloated or make the bowels distended,” says Dr. Jeffrey Milson, a surgeon at NewYork-Presbyterian/ Weill Cornell. “It also quickly deflates, giving us room to remove the polyp.

“It’s reassuring to our patients getting preventive colonoscopies that no matter what kind of polyp we find, in almost all instances, we can remove it with minimal discomfort and inconvenience,” he adds.

Milson believes that most, if not all surgeries for difficult intestinal polyps nationwide will be preformed laparoscopically. Chief factors are that technology is rapidly improving and is allowing surgeons to do more complicated procedures with minimal invasiveness.

Due to new tools such as high-definition television, the industry is in the “midst of a huge upsurge,” Milson says.

Learning Curve

Laparoscopic surgery affords many conveniences, but learning it is not one of them. The skills required are more technically demanding, after all, than traditional open surgery methods, according to an article in AORN Journal, “Future Trends in Minimally Invasive Surgery.” “Surgeons and nurses are working in smaller anatomical areas while employing a mental three-dimensional picture of the patient’s body,” the author states. “Using instruments like trocars, endoscopes, and cameras requires some degree of technological know-how that may present a disadvantage to people who did not grow up in a video-inundated world.

“Scalpels attached to long wands can be more difficult to maneuver than short, traditional ones, as are clips and sutures on the ends of long wands,” the author continues. “It is possible to cause unintentional bleeding or trauma to anatomy that is not in the direct view of the camera head. These problems, however, are conquered with experience.”

Attrition in the surgeon ranks will surely lead to a new breed of surgeons who are all trained in laparoscopic procedures, says Christoudias.

“As time goes by, and the older age group surgeons retire, we will have an increase in the procedures done laparoscopically, at the expense of the open procedures,” he says. “The obvious question then, is how well is the new generation of surgeons going to be prepared when the need for an open procedure arises.”

A worthy question, that only time can answer.

“For the surgeons that have been doing only open surgery, it is very challenging indeed (to learn laparoscopic),” Christoudias continues. “They have to learn to do the same procedures in a completely new and different way. For the surgical residents, is not at all more challenging than learning to do open procedures.

“To the contrary, I think it will be easier learning MIS, because they can see, and follow the entire procedure, just by looking on the monitor, even if they are second, or third assistant,” he adds. “This was not possible in open surgery, where, unless you are the surgeon or first assistant you have to keep your head out of the way and keep pulling the retractor as instructed by the surgeon.”

Big Business

Minimally invasive surgery may cost the healthcare system less overall, but putting together an MIS operating suite isn’t cheap by any means.

Compiling such a suite can cost $200,000 to $300,000 per room,³ but choosing reusable equipment instead of disposable equipment may help, according to the author of, “Future trends in minimally invasive surgery.”

“Studies show that laparoscopic surgery that uses reusable instruments such as sheaths, trocars, and other equipment that is autoclaved and cleaned is less expensive than using disposable equipment,” the author states.

Investing in the future of MIS has been lucrative for many ASC partners, and will continue to be. As stated in a report, “Trends in the Noninvasive and Minimally Invasive Medical Device Market,” the global MIS device and instrument market was worth about $12 billion in 2005, and will likely reach $12.9 billion in 2006 and $18.5 billion by 2011. That’s an annual growth rate of 7.5 percent between 2006 and 2011.¹ “The U.S. accounted for about 60 percent of the world market, or $7.2 billion in 2005, and is growing at an AAGR of 7.2 percent,” the paper states. “The U.S. market should reach $7.7 billion in 2006 and $11.0 billion by 2011.”

Surgical devices are the biggest product segment of the U.S. MIS market, of which they accounted for about a 69 percent share in 2005.¹ “Monitoring and visualization systems were the second largest segment of the U.S. market in 2005, with an 11 percent market share, followed by endosurgical instruments (10 percent), electrosurgical equipment (8 percent), and robotics (2 percent),” the authors state. 

1. Trends in the noninvasive and minimally invasive medical device market. BCC Research. June 2006.

2. New combined laparoscopy and colonoscopy procedure may avoid need for major surgery. New York-Presbyterian Hospital/Weill Cornell Medical Center/Weill Cornell Medical College.

3. Cook N. Future trends in minimally invasive surgery. AORN Journal. Dec. 2005.

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